Evaluation of Botox as Bridging Therapy for Peroral Endoscopic Myotomy: A Retrospective Analysis

Aims Botulinum toxin injection (BTI) can be used as a bridging therapy for patients awaiting peroral endoscopic myotomy (POEM). However, previous treatments (BTI, dilation, or Heller myotomy) had been associated with fibrosis and technical difficulties. The aim of this study is to evaluate whether prior BTI affects the safety and efficacy outcomes of POEM.

Methods We conducted a retrospective single-center analysis of POEM cases performed between July 2019 and July 2024 at our center, comparing clinical and endoscopic variables (including fibrosis and intra-procedural events) between two patient groups: A) those receiving only BTI before POEM and B) patients that have not undergone any treatment before POEM (naïve). Efficacy was defined as an Eckardt score (ES) of<3 points post-POEM. Intra-procedural events included intra-procedural bleeding that required an hemostatic forceps for hemostasis, capnoperitoneum, mucosal transmural defect and superficial mucosal injury (suspected mild mucosal damage without evident transmural defect including coagulation “white dots” or mild erosions) [1].

Results A total of 122 POEM procedures were performed. Among those, 53 patients were excluded because they had previously undergone Heller myotomy or dilation (even if they had also received BTI), leaving 69 patients for analysis: Group A) 10 patients (14.5%) who received only BTI before POEM and Group B) 59 patients (85.5%) who were naïve. The indication for BTI as a bridging therapy before POEM was 30%. There were no significant differences in gender, age, type of achalasia and ES prior to POEM between the two groups. POEM was equally successful in both groups, 100% (10 patients) of the TBI group and 91.5% (54 patients) of the naïve cohort (p=1). The presence of fibrosis was greater in the BTI group but not statistically significant (30% in the prior BTI group vs. 8.5% in the naïve group, p=0.394). No differences were found in the rate of intra-procedural events between the groups. Regarding the procedure duration, there were no significant differences between both groups in the overall POEM time (56.6 minutes, p=0.776) and any of the steps (mucosal incision, tunnel time, myotomy time).

Conclusions Although there may be a greater tendency towards fibrosis (statistically not significant) in the group with TBI, in our series, TBI does not appear to affect the outcomes of POEM, and no differences were found in the procedure time. TBI may be considered as a bridging therapy for patients with achalasia awaiting POEM. Further studies with a larger patient sample are recommended.

Publication History

Article published online:
27 March 2025

• References

• 1 Wu QN, Xu XY, Zhang XC, Xu MD, Zhang YQ, Chen WF, Cai MY, Qin WZ, Hu JW, Yao LQ, Li QL, Zhou PH.. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy 2017; 49 (8): 736-744 Epub 2017 Jun 28. PMID: 28658680